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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or-install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address J�C.[city Lot Size PM <br /> Owner's Name1~ J t • r f. Addre'ss ` �'7' ('s � __ Phone *16,2` �Pj <br /> i /A� C fps <br /> ConttactorL _ Address._�/ /I' �iR _ License No.� 5 Phone--A-4—4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ' . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. Y}PROP.:.LINE i <br /> FOUNDATION AGRICULTURE_WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS J' <br /> ❑ Industrial LI Open Bottom ❑ Manteca Dia. of Well Excavation Dia;of Well Casing . <br /> D Domestic/Private ❑ Gravel Pack ❑ Tracy- r Type of Casing `z Specifications { <br /> C] Public Cl Other Cl Delia Depth of Grout Seal Type of!Grout <br /> I I Irrigation --Approx. Depth I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump -11l.P. State•Work bone <br /> Well Destruction ❑ Well Diameter sealing Material Itop 50'l <br /> s Depth ± Filler Material (Below 50') `v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is ` <br /> I ! available within 200 feet.i ; <br /> Installation will serve: Residence Commercial_ Other Wa j + <br /> c Number of living units: Number of be s A I <br /> Character of soil to a depth of 3 feet: Water table depth_ <br /> SEPTIC TANK ❑ ,Type/Mf! #0 Ca acityrU� , No. Compartments 10( i <br /> PKG. TREATMENT PLT. ❑ s x� �..l ' ' ��r'� Method of Disposal f <br /> Distance to nearest: Well-_ Foundation � w-�Property Line <br /> LEACHING LINE ❑ No & Length of lines <br /> 9 Total length/size <br /> FILTER BED ❑ Distance to_nearest h .:Wein Foundation. .Property Line '*s <br /> SEEPAGE PITS r (I I` DepthLanber <br /> J f <br /> SUMPS L� Distance to nearest: Well o .Foundation 2�W• ;Property Line i <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the-work will be done in accordance witW§an Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. : + <br /> Home owner or licensed agent's signature certifies th&following. x <br /> 9 g g: "I certify that in the performance bfothe wtitk-for which this <br /> employ any person in such manner as to become subject to workman's compensation la3us of Californiapermit is issued, I shall not <br /> ." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st call for ai quired i ctions. Complete drawing on reverse side. 'A <br /> Signed X .r <br /> 9 Title: r ' Date: <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by Vm <br /> Date <br /> Pit or Grout Inspection.bye Date Final Inspection by / l Date <br /> Additional Comments: * b s S` ` ` ti <br /> ir <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E> Hazelton Ave.,,P D. Box 2009, Stk., CA 95201 i <br /> r <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13.24(REV.1/x 5) 90 <br /> EH 14-26 1�+� may_/� � p„rS <br />